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A) Based on document review and interview it was determined for 4 of 4 employee records reviewed, the CAH failed to staff the emergency department with staff who possess the education and specialized training to respond to the emergency medical needs and care of the patient population being served.

Findings include:

1 . The employee files for E #2, E #5, E #7, and E #8 were reviewed on 2/19/25 at approximately 12:00 PM. All employee files lacked documentation of training related to the care of mental health patients such as elopement prevention, de-escalation training, and patient one-on-one education/training.

2. An interview was conducted with Quality Improvement (E #1) on 2/19/25 at approximately 2:30 PM. While discussing documentation of employee training related to elopement prevention, de-escalation training, and patient one-to-one sitter training, E #1 stated, "I will not be able to provide any documentation of staff completing those trainings. I am a CPI (Crisis Prevention Intervention) instructor. The facility does not hold CPI classes for the staff and we do not have a training program that covers those topics."




B) Based on document review and interview it was determined for 1 of 5 (Pt #7) patients records reviewed, the CAH failed to monitor the patient appropriately which allowed Pt #7 to elope twice.

Findings include:

1. The policy titled "Sitters" (effective 7/2019) was reviewed on 2/18/25 at approximately 11:00 AM. The policy states, " ...Keep the patient in view at all times ..."

2. Pt #7's medical record was reviewed throughout the survey. The medical record noted Pt #7 presented to the Emergency Department (ED) on 1/9/25 at 6:21 AM for a psych evaluation. Pt #7 eloped from the ED at 10:06 AM. Pt #7 was brought back to the ED by police at 10:20 AM. Pt #7 assaulted staff, eloped from the ED a second time, and stole and wrecked an ambulance. The record lacked documentation of the time of the second elopement.

3. An interview was conducted with RN ED Manager (E #4) on 2/18/25 at approximately 12:00 PM. While discussing the 1:1 supervision for Pt #7 on 1/9/25, E #4 stated, "The first time, (E #8) was across the hall watching (Pt #7) through the door. The second time, (E #8) was right outside the door."

Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to provide safe care and services. Therefore the Condition of Participation 42 CFR 485.635, Provision of Services, was not met.

Findings include:


1. The hospital failed to develop policies and procedures for providing emergency services to patients experiencing a mental health crisis (suicidal).

2. The Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints.

A. Based on document review, and interview, it was determined the critical access hospital failed to develop policies and procedures for providing emergency services to patients experiencing a mental health crisis (suicidal).

Findings Include:

1. The policy titled "Self Harm (Suicide Precautions)" (revised 5/28/2024) was reviewed on 2/19/2025 at 3:00 PM and indicated, " ...The nursing staff shall implement the Psychiatry Observation Sheet and suicide precautions while awaiting Physician/Provider order and remain 1:1 with the patient until provider assessment ..."

2. An interview was conducted on 2/19/2025 at 2:30 PM with Quality Improvement (E # 1). While discussing suicide precautions, E #1 stated, "We can spell it out for you, but we don't have a policy or procedure in writing that describes what is included with suicide precautions."




B. Based on document review and interview, it was determined for 1 of 1 (Pt #7) patient records reviewed, who required the use of violent restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints.

Findings include:

1. The Policy titled "Restraint and Seclusion Use (revised 7/2019)" was reviewed on 2/20/2025 at approximately 1:00 PM. The policy noted, "Restraint Or Seclusion Orders: " ... Each episode of restraint use must be initiated in accordance with the order of an MD (Medical Doctor)/ DO (Doctor of Osteopathic Medicine) or other LIP (licensed Independent Practitioner) ... The attending physician shall be consulted as soon as possible if the attending physician did not order the restraint or seclusion." "Procedure: ...Verify that the order for restraint or seclusion includes rationale for restraint, length of time and type of restraints to be used, and the extremity or body part(s) to be restrained."

2. The clinical record of Pt #7 was reviewed on 2/19/2025 at approximately 11:00 AM. Pt #7 was placed in 4-point leather restraints on 1/9/2025 at 2:00 PM. Pt #7's record lacked an order for restraints.

3. An interview was conducted on 2/20/2025 at approximately 10:30 AM with Quality Improvement (E #1). E #1 reviewed Pt #7's record and stated, "There is no order for restraint placement. The nurses received a verbal order, but due to the craziness of the day it was likely missed. It should have been placed in the system and was not."